1. That for and on behalf of Myself and My wife and children and remitter issue wholly renounce/relinquish and abandon the use of my former name/ surname of ................... and in place thereof I do hereby assume from this date the name/surname ................. and so that I and
my wife and children remitter issue may hereafter be called, known and distinguished not by my former name/surname. but by assumed name/surname of .....................................

2. That for the purpose of evidencing such my determination declare that I shall at all times hereafter in all records, deeds and writings and in all preceedings, dealings and transactions, private as well as upon all occassions what-so-ever use and sign the name of ..................... as my name/surname in place and in substitution of my former name /surname.

3. That I expressly authorize and request all persons in general relatives and friends in particular at all times hereafter to designate and address me. my wife, my children. remitter issue by such assumed name/surname of .......................................... accordingly.

4. In witness whereof I have here unto subscribed my former and adopted name/ surname of ....................................... and ............................... affix my signature and seal. if any,
this ............................ day of ...............................
Date ........................ Signed sealed and delivered by the above name

former name ...................................................
In the presence of .............................................
Name .....................................
Address ......................................
Name
Address

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